Treatment Plan for Recurrent Lower Back Pain with Radiculopathy
Start NSAIDs combined with a skeletal muscle relaxant for 7-10 days, advise the patient to remain active, and restart physical therapy immediately. 1, 2, 3
Immediate Pharmacologic Management
Prescribe NSAIDs (such as naproxen or ibuprofen 400mg three times daily) as first-line medication, as they provide small to moderate pain relief superior to acetaminophen for acute exacerbations of low back pain. 1, 2 Use the lowest effective dose for the shortest duration necessary, and assess cardiovascular and gastrointestinal risk factors before prescribing. 2
Add a skeletal muscle relaxant (such as cyclobenzaprine or chlorzoxazone) for short-term relief since the patient reports pressure-type pain exacerbated by standing, suggesting muscle spasm contribution. 4, 2, 5 The combination of NSAIDs plus muscle relaxants demonstrates superior efficacy compared to NSAIDs alone, with faster resolution of functional deficits and greater improvement in objective muscle spasm. 5, 3 Prescribe time-limited courses only (7-10 days maximum) and warn the patient about sedation as the primary side effect. 2, 5
Avoid opioids entirely at this stage, as the patient's pain is 4/10 and not severe enough to warrant opioid therapy given substantial risks of abuse and addiction. 1, 2 The patient previously improved with conservative treatment, indicating she is likely to respond again without opioids. 4
Essential Non-Pharmacologic Interventions
Advise the patient to remain active and avoid bed rest, as activity restriction prolongs recovery and delays resumption of normal activities. 4, 1, 2 Since she reports pain exacerbated by standing, recommend frequent position changes and short walks rather than prolonged standing or sitting. 1
Recommend application of superficial heat using heating pads for short-term symptomatic relief. 1, 2
Refer immediately to physical therapy or physiotherapy for supervised exercise therapy, as this is a core component of multimodal management for low back pain with radiculopathy. 4 The patient previously improved with treatment, suggesting she will respond well to structured rehabilitation. 4
Imaging Considerations
Do not order new imaging at this visit, as the patient has recent MRI findings (showing disc bulges and protrusions at L3-4, L4-5, and L5-S1) and no red flags suggesting progression to serious pathology. 4, 1 She denies numbness or tingling, indicating no new neurologic deficits. 4, 1
MRI findings of disc bulges and protrusions are often nonspecific and do not necessarily correlate with symptom severity or predict treatment response. 4, 6 Her symptoms switching from right to left leg radiation suggests functional/mechanical pain rather than progressive structural pathology. 4
When to Escalate Care
Reevaluate in 2-4 weeks to assess response to treatment. 4, 1 If symptoms persist beyond 4-6 weeks without improvement despite conservative therapy, consider:
- Epidural steroid injection if radicular symptoms persist and she remains a surgical candidate. 4
- Referral to pain management for more detailed education on pain management strategies and goal-oriented care planning. 4
- Spinal manipulation by appropriately trained providers (chiropractor or osteopath) if initial treatment fails, as this shows small to moderate short-term benefits. 2, 7
Obtain urgent MRI and neurosurgical consultation only if she develops progressive neurologic deficits, cauda equina symptoms (bowel/bladder dysfunction, saddle anesthesia), or severe unrelenting pain unresponsive to all conservative measures. 4, 1
Psychological and Functional Assessment
Screen for psychosocial risk factors including anxiety, depression, catastrophizing, fear-avoidance beliefs, and job dissatisfaction, as these predict progression to chronic disabling pain. 1 Consider using the STarT Back tool at the 2-week follow-up to risk-stratify and direct resources appropriately. 1
If high psychosocial risk is identified, refer for comprehensive biopsychosocial assessment and consider cognitive behavioral therapy or mindfulness-based interventions. 4, 1
Critical Pitfalls to Avoid
Do not prescribe bed rest or activity restriction, as this provides no benefit and delays recovery. 4, 1, 2
Do not assume the MRI findings explain all symptoms, as disc bulges and protrusions are common incidental findings in asymptomatic individuals and may not correlate with her current left-sided radicular pain. 4, 6
Do not continue medications beyond 2-4 weeks without clear evidence of ongoing benefits, and monitor for adverse effects including gastrointestinal bleeding with NSAIDs and sedation with muscle relaxants. 2, 5